Mind-body role may matter in heart disease

Could screening for and treating depression and anxiety reduce the risk of heart disease?
Given that research is increasingly indicating a relationship, if not a causal link,
internists may want to more proactively consider the possibility with their patients,
according to experts.

Data clearly show that having an acute cardiovascular problem like a heart attack
or need for a defibrillator can cause huge emotional distress. However, studies looking
at the association between depression and an increased risk of developing heart disease
aren't as clear. The studies are either observational or show that while patients
who get antidepressants are less depressed, their mortality outcomes are no different.

Part of the problem is that the studies are not truly randomized clinical trials,
said Richard Josephson, MD, professor of medicine at Case Western Reserve University
School of Medicine and director of cardiac intensive care and cardiovascular and pulmonary
rehabilitation at University Hospitals, both in Cleveland. “You can't randomize
people to be depressed or not or to have heart attack or not, so it's hard to see
how randomized placebo trials can ever occur,” he said. “So for people
who believe randomized clinical trial data is the only standard, then [a link between
mental health concerns and heart disease] doesn't exist.”

Even without reaching that gold standard, however, he contended there is enough evidence
showing that depression and anxiety are modifiable risk factors for heart disease
to prompt primary care physicians to be proactive. They can do that by coming up with
a differential diagnosis that can be treated with targeted mental health interventions,
he said. Such interventions can help break the cycle of patients who are too depressed
to comply with heart-healthy behavior such as quitting smoking, exercising, and lowering
alcohol intake, he noted.

Even if the link—not everyone will call it a risk factor—hasn't been
completely vetted, internists can't go wrong by looking for clues to effectively treat
the whole patient, advised Nieca Goldberg, MD, ACP Member, a cardiologist and medical
director of the Joan Tisch Center for Women's Health at NYU Langone Medical Center
in New York.

“Physicians should use their clinical skills to assess whether a person has
primary arrhythmia or if the hypertension is related to anxiety,” she said.
“Our job as physicians is not only to treat the blood pressure but also to
help the patient have a better quality of life.”

Looking at the connection

It makes sense that a heart attack could lead to depressive symptoms or exacerbate
preexisting ones, Dr. Josephson said. There are enough data, albeit not from randomized
controlled trials, to lead the American Heart Association to issue a recent scientific
statement that depression should be considered a risk factor for heart disease.

The relationship is independent of other stresses and occurs more in smokers, older
people, single versus married people, and those of low socioeconomic status, he said.

Severe depression after a heart attack is related to a preexisting diagnosis of depression
prior to the index event. “Someone hospitalized for depression 10 years ago
who now has a heart attack is at extremely high risk of major depression thereafter,”
he said.

But the conversation is murkier when looking at whether depression or anxiety leads
to cardiovascular risk.

Studies, including a recent one by Goldie and colleagues presented last October at
a meeting of the Canadian Cardiovascular Congress, show an association, not a causal
relationship, between mental disorders and heart disease.

However, Dr. Josephson said, there are many studies showing that there is autonomic
system dysfunction after MI, and this dysfunction correlates with an adverse prognosis.
He was part of a study showing that the dysfunction correlated strongly with fitness,
which strongly suggests that the mechanism of post-MI adverse prognosis may involve
physical inactivity or lack of fitness.

He added that physical activity, perhaps via a structured program such as cardiac
rehabilitation, may fundamentally improve a patient's prognosis.

“What convinces me is that the mechanistic studies in recent years are in an
area where you can't do the most desired randomized trial,” he said.

Dr. Goldberg said physical evidence seen in studies includes that depressed patients'
platelets are more likely to clot prior to therapy and that an association exists
between increased anxiety and higher blood pressure.

“Physiologically we know stress and anxiety raises blood pressure and heart
rate, so patients are more likely to report palpitations,” she said.

Studies on post-traumatic stress disorder (PTSD) are also showing an association with
heart disease, from decreased cardiac blood flow to increased risk of heart disease
events, said Beth Cohen, MD, associate professor of medicine at the University of
California San Francisco and staff physician at the San Francisco Veterans Affairs
Medical Center. She is also principal investigator of the Mind Your Heart Study, which
is looking at the biological, behavioral, and psychosocial factors that increase chronic
disease risk in patients with PTSD.

However, she said the reasons behind the findings, whether they are because of poor
health behaviors, a biologic factor, or something else, are still fuzzy, making it
unclear if patients who get treatment are less likely to have future disorders.

“We need to determine the specific mechanisms so we can develop new targeted
treatments to prevent cardiac events in patients with mental health disorders,”
Dr. Cohen said.

Opening a door

Findings of association should be enough to spur internists to open the door to a
conversation with patients, especially those with adherence issues, and to consider
whether there is depression or anxiety, Dr. Cohen said.

Even the SADHART study, which found that patients treated with medications had improved
moods although cardiovascular outcomes remained the same, should be considered encouraging,
she said.

“If you improve mood that's a good thing, because it can increase compliance
with medications and healthy lifestyle recommendations,” Dr. Cohen said.

Internists who typically use a screening tool such as the PHQ-9 to detect depression
should recognize its limitations, Dr. Josephson said. While it is an excellent screening
tool for use by internists, it is not considered the gold standard, which is a structured
clinical interview for depression.

“The PHQ-9 is fine for clinical application, but some of the ‘noise’
in research data likely relates to the PHQ-9's imperfections,” he said.

It can help, though, by distinguishing between an adjustment disorder characterized
by sadness and appetite disturbance and complete debilitation or major depressive
disorder, said Barry J. Jacobs, PsyD, director of behavioral sciences for the Crozer-Keystone
family medicine residency program in Springfield, Pa. An internist can monitor the
former and treat or refer the latter.

“Some [physicians] say, ‘Of course the patient is depressed. They've
had a heart attack.’ They label it as normal adjustment reaction, which misses
the mark,” he said. “They don't take into account a pathological condition
which could be treated.”

To differentiate for a depression diagnosis, look for someone with a minimum of 2
weeks of symptoms and for moderate to severe depression and symptoms most of the day
nearly every day, said Mary F. Morrison, MD, FACP, professor of psychiatry and internal
medicine at Temple University School of Medicine in Philadelphia. There are both psychological
symptoms of depression and physical symptoms (such as changes in appetite and sleep
and fatigue).

Look for patients who express a lack of enjoyment in previously enjoyable activities,
especially for those whose depressive post-cardiac event symptoms do not get better
with time, added Dr. Josephson.

Patient management tips

A proven beneficial intervention for patients struggling with depression and anxiety
is exercise, whether the patient is at risk for or has had a cardiovascular event,
said Dr. Josephson. It may be enough for those with milder depressive symptoms.

“There's no question that regular exercise after a heart attack or bypass surgery
cuts down the risk of depression, and to lesser extent anxiety, among other good things,”
he said. Cardiac rehab, he noted, is recommended and associated with better quality
of life and lower mortality.

Exercise has its benefits for at-risk patients as well. “Depressed people tend
to be couch potatoes, so being depressed and less active may be the mechanism of depression
that affects cardiovascular health,” he said.

Because exercise changes the autonomic nervous system, it may not only treat the symptoms
of depression but also improve cardiovascular outcomes, he explained.

“Antidepressants make you feel better but not improve mortality,” he
said. “Exercise makes you feel better and may affect fundamental biology.”

But it's not a cure-all, he pointed out. “There's much reason to think exercise
will diminish but not totally eliminate the risk of future cardiovascular disease,”
he said.

In addition to exercise, Dr. Jacobs said a patient's mental wellness plan should include
a 20-minute daily relaxation technique such as doing breathing exercises or practicing
yoga or meditation.

“Cognitive behavioral therapy is based on the premise that what we subconsciously
say to ourselves has an impact on how we view the world and how stressed we become,”
he said. Negative thinking can make patients more unhappy and stressed out.

“So maintaining cautious optimism ... a sense of hopefulness that we have the
capacity to improve or manage a condition matters a lot,” he said.

As part of that plan, physicians should address social isolation.

People who have had a serious medical event or are depressed tend to isolate themselves
just at the time when they're most vulnerable and could benefit from social support,
Dr. Jacobs said. That strategy can backfire.

“People with a lack of support are at higher risk for depression and further
adverse medical events,” he said.

He recommended that patients reach out to family members, return to church, and get
back in touch with friends.

Virtual connections can also help, he said, pointing to the American Heart Association's
recently launched network to connect heart disease survivors and their caregivers with others.

While medications can be useful, some drugs intended for major depressive disorders
can contribute to lethargy and weight gain, Dr. Josephson said, noting that most primary
care physicians are more likely to prescribe selective serotonin reuptake inhibitors
that are unlikely to have those side effects. Dr. Morrison cautioned against prescribing
relatively new antipsychotics without carefully reviewing the risks and benefits.
“Antipsychotics can be part of the problem,” she said. “Their
adverse effects on lipids and weight are huge.”

If medications aren't working, find out how depression is affecting patients' lifestyles
and whether they're physically or socially active. Then follow up to look for clinical
changes and if necessary adjust the dosage or switch to a different medication, Dr.
Josephson said.

When to refer

Doctors should start a conversation with their patients with a referral team in place,
experts noted.

While some internists have more training, experience, and even the disposition to
handle patients with depression and anxiety, it's important to know when to refer
the patient to a professional. A red flag is if a trial of antidepressant therapy
in a reasonable amount of time is not helping the patient or if the patient is being
nonadherent, said Dr. Goldberg.

“If you feel like you're refilling benzodiazepines and other anxiety medications
too many times, then your patient needs to see a mental health professional,”
she said.

“People don't want to hear, ‘You need to see a psychiatrist.’
They want to know why, with the doctor's care, it's so hard for them to get better,”
she said.

Explain that despite all the things you do to improve physical health, one outlier
is that anxiety or even depression can contribute to poor adherence and less positive
outcomes, she said.

Patients are often open to the idea, Dr. Cohen said. “Patients are often relieved
when someone understands that physical and emotional pains are linked,” she
said.

When one of her patients in her 50s who had had stents, bypass surgery, diabetes,
hypertension, and hyperlipidemia didn't schedule follow-up visits and lab testing
or exercise, Dr. Goldberg felt she needed to make a referral.

“I said, ‘I know you're a smart, responsible person and I can't believe
you forget to do this. I want to work with you on compliance to medications, diet,
and exercise and refer you to a psychologist,’” she said. It worked.
The patient now shows up for regular visits and follows through with lab tests.

“She's doing well and thanks me all the time,” Dr. Goldberg said.

The outlook

Given the debate over the scientific evidence, or lack thereof, future studies should
look more closely at the connection between heart conditions and depression and anxiety,
said Dr. Morrison. She said specific attention should be paid to the changes in the
autonomic nervous system that occur with depression, as well as the impact of mindfulness
or biofeedback on mortality.

Even with those unanswered questions, she said it pays to treat the depression.

“We hope heart health improves from the point of view that people have more
energy, feel better, and are more likely to take their medications,” she said.

With more focus in medical training and continuing medical education, internists are
better equipped than ever to handle these complicated patients, Dr. Cohen said.

“There's a huge surge in mind/body health. I think culture is changing around
that,” she said.

And the potential link between mental health and heart disease adds more heft to the
connection.

“There are already lots of reasons to treat the depression,” Dr. Josephson
said. “The link to cardiovascular disease is another.”

Lichtman JH, Froelicher ES, Blumenthal JA, Carney RM, Doering LV, Frasure-Smith N,
et al; American Heart Association Statistics Committee of the Council on Epidemiology
and Prevention and the Council on Cardiovascular and Stroke Nursing. Depression as a risk factor for poor prognosis among patients with acute coronary
syndrome: systematic review and recommendations: a scientific statement from the American
Heart Association. Circulation. 2014;129:1350-69. [PMID: 24566200] doi:10.1161/CIR.0000000000000019

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